Article Detail - JD DME

Outlined below are the principal changes to the DME MAC Policy Articles (PAs) that have been revised and posted. The policies included are Ankle-Foot/Knee-Ankle-Foot Orthoses, Lower Limb Prostheses, Manual Wheelchair Bases, Orthopedic Footwear, Refractive Lenses, and Transcutaneous Electrical Nerve Stimulators (TENS). Please review the entire Local Coverage Determinations (LCDs) and related PAs for complete information.

Ankle-Foot/Knee-Ankle-Foot Orthoses

PA

Revision Effective Date: 02/01/2021
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: “Braces Benefit” to “braces benefit”
Revised: “Coding Guidelines” to “CODING GUIDELINES”
Revised: “Ankle-Foot Orthosis” to “ankle-foot orthosis”
Revised: “CAD-CAM” to “computer-aided design/computer-aided manufacturing (CAD/CAM)”
GENERAL REQUIREMENTS:
Revised: “Coding Guidelines” to “CODING GUIDELINES”
Revised: “off-the-self” to “OTS”
MODIFIERS:
Revised: “KX, GA, and GZ MODIFIERS:” to “GA, GZ, KX, LT and RT MODIFIERS:”
Added: Statement regarding use of RT and LT, with reference to CODING GUIDELINES section for additional information
CODING GUIDELINES:
Revised: Language describing parallel code set availability for identical types of products
Revised: Coding guideline language for HCPCS codes L1900, L1902, L1904, L1906, L1907, L1910, L1920, L1930, L1932, L1940, L1945, L1950, L1951, L1960, L1970, L1971, L1980, L1990, and L2006
Revised: Coding guideline information for HCPCS codes L1910, L1932, and L1951, to include that there are no additional HCPCS codes for these types of orthoses
Added: Long HCPCS descriptions to coding guidelines for HCPCS codes L2006, L2340, and L2755
Revised: Language describing the coding of foot orthotics as L-codes or A-codes
Revised: “Durable Medical Equipment” to “durable medical equipment”
Revised: “Braces” to “braces”
Revised: Format of long HCPCS descriptions for HCPCS codes A9270 and L4205

05/26/2022: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Lower Limb Prostheses

PA

Revision Effective Date: 08/01/2020
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: “beneficiary to be eligible” to “beneficiary’s lower limb prosthesis to be eligible” in regard to eligibility for reimbursement
CONTINUED MEDICAL NEED:
Added: Section header and continued medical need language
MODIFIERS:
Added: Section Header and “RT and LT MODIFIERS:”
Added: Statement regarding use of RT and LT, with reference to CODING GUIDELINES section for additional information
CODING GUIDELINES:
Added: L5781, L5782, L5985, L5988, L5000, L5010, and L5020 coding guidelines
Revised: “ANKLES” to “ANKLE AND LOWER EXTREMITY MOTION UNITS”
Revised: Statement pertaining to products that provide single motion or combination of motions, to include HCPCS codes L5985 and L5988 and to note “functional movement of lower limb during ambulation”
Added: “manufactured by R.G. Rincoe & Associates, Inc.” to L5968 coding guideline predicate product information
Added: “PARTIAL FOOT AND TOE FILLER INSERTS”
Removed: “MODIFIERS”
CODING VERIFICATION REVIEW:
Revised: Location of coding verification review information

05/26/2022: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Manual Wheelchair Bases

PA

Revision Effective Date: 01/01/2020
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Removed: Reference to ADMC program-specific information

05/26/2022: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Orthopedic Footwear

PA

Revision Effective Date: 01/01/2020
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: L5220 to the list of partial foot or lower extremity prosthesis HCPCS codes that will result in orthopedic shoes denial when the shoes are put on over the prosthesis
MODIFIERS:
Added: LT and RT modifiers
Removed: “code (specific to the 5th digit)”
Added: “code(s) to the highest level of specificity”
Added: Statement regarding use of RT and LT, with reference to CODING GUIDELINES section for additional information
CODING GUIDELINES:
Added: L5220 to the list of other types of leg prostheses that must not be used with HCPCS code L3250

05/26/2022: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Refractive Lenses

PA

Revision Effective Date: 10/01/2020
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: "Prosthetics and Artificial Limbs" to "prosthetic devices"
CONTINUED MEDICAL NEED:
Added: Section header and continued medical need language
 
05/26/2022: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Transcutaneous Electrical Nerve Stimulators (TENS)

PA

Revision History Effective Date: 11/20/2021
MODIFIERS:
Removed: Q0 (zero) modifier from sub-header, modifier details previously removed

05/26/2022: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Note: The information contained in this article is only a summary of revisions to the LCDs and/or PAs. For complete information on any topic, you must review the LCDs and/or PAs.

With the update(s) listed above, Noridian would like to remind users how to find the policy that was previously effective. When billing, the supplier should follow guidance that was effective on the date of service. The below steps can be followed to find all previous policies:

1. Open the currently effective policy on the Medical Coverage Database (MCD)
   1. Links to the MCD can be found on the Active LCDs page on the Noridian website
      1. There is a link at the top of the Active LCD page that goes to a full list of the LCDs or PAs, depending on which link is selected OR
      2. There are direct links to all LCDs under the ‘LCD ID number and Effective Date’ column
2. Scroll down to the bottom of the policy
3. Find the section labeled Public Version(s)
4. Look for the link to the policy that was effective on the dates of service in question
5. Click on hyperlink to go to the policy